King Faisal Specialist Hospital & Research Centre Employee Safety Manual Revised: Muharram

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5 TABLE OF CONTENTS PREFACE CHAPTER 1 ACCOUNTABILITY AND RESPONSIBILITIES FORWARD FROM COLONEL/MOHAMMED AL SHEHRI...16 MESSAGE FROM THE CED (HOSPITAL SAFETY POLICY STATEMENT)..17 MESSAGE FROM THE CED (HOSPITAL SAFETY POLICY STATEMENT) ARABIC..18 INTRODUCTION.19 PURPOSE...20 RESPONSIBILITY EMPLOYEE AND SUPERVISOR RESPONSIBILITY...21 SAFETY SECTION RESPONSIBILITY AND YOU 21 SELF PROTECTION 22 COMMITTEES SERVING SAFETY.23 HOSPITAL I.D. BADGES & PERMITS 24 CHAPTER 2 SURVEYS AND TRAINING SURVEYS/INSPECTIONS / SAFETY MEETINGS.27 SAFETY TRAINING AND EDUCATION.28 New Employee Orientation Continuous Fire and Safety/Loss Prevention Training Department Specific Hazards and Education Experienced Based Training DOCUMENTATION.30 TECHNIQUES TO MEASURE SAFETY PERFORMANCE..31 CHAPTER 3 KFSH&RC EMERGENCY MANAGEMENT PLANS AND SECURITY...32 EMERGENCY FIRE PROCEDURES 33 KFSH&RC FIRE ALARM SYSTEMS...36 FIXED EXTINGUISHING SYSTEMS...37 Halon 1301 Water Sprinkler System Fixed Dry Chemical (ABC) System Fixed CO 2 System EMERGENCY RESPONSE PERSONNEL...38 Emergency Handling Procedures - 5 -

6 CHAPTER 3 KFSH&RC EMERGENCY MANAGEMENT PLANS AND SECURITY continued YOUR FIRE EXTINGUISHER KNOW IT AND USE IT 39 SECURITY 41 ACCESS CONTROL 42 COMMUNICATIONS SERVICES.43 INTERNAL DISASTER SITUATION LEVEL CHART.44 CHAPTER 4 PATIENT, VISITOR AND EMPLOYEE SAFETY 46 PATIENT SAFETY 47 Safety Guidelines for Patients Escorting and Transporting Patients Lifting and Carrying Patients Evacuating Patients MEDEVAC.57 VISITOR SAFETY.58 EMPLOYEE SAFETY..59 Introduction Employee Exposure Determination The Gasic General Safety Rules CHAPTER 5 SAFETY BY DEPARTMENT 68 ANESTHESIOLOGY 71 CSSD...72 Ethylene Oxide Hazardous Materials and Waste CLINICAL ENGINEERING 72 ENVIRONMENTAL SERVICES...72 Housekeeping Laundry Hazardous Materials and Waste FOOD SERVICES.78 Guidelines Kitchen Appliance Safety Tips Towing Tugs LABORATORY SAFETY.. 82 General Safety Requirements Chemical Hygiene Plan Principle Safety Rules - 6 -

7 CHAPTER 5 SAFETY BY DEPARTMENT continued Radiation Safety MSDS Needlestick Prevention Hazardous Material & Waste LOGISTIC SERVICES. 91 Material Handling How to Lift and Carry Materials Safely Forklift Operation Safety Picker Truck Ladder Safety Compressed Gas Cylinders Fuel and LOX Hazardous Material and Waste NURSING SERVICES...99 Principle Safety Rules Infection Control In-Patient Chemotherapy Home Health Care Chemotherapy Administration Isolation Policy Special Care Units Dialysis Radiation Safety Needlestick Prevention Hazardous Materials and Waste PHARMACY 102 Basic Safety Guidelines Explosive and Flammable Safety Measures in the Pharmacy Hazardous Materials & Waste RADIOLOGY..104 General Diagnostic Radiology Fluoroscopic Procedures Dental Radiology Nuclear Medicine and Radiation Therapy Teletherapy Sealed Source Rupture Radioactive Liquid Spills Radiation Safety RESEARCH CENTRE 107 Radiation Safety Laser Safety Chemical Safety - 7 -

8 CHAPTER 5 SAFETY BY DEPARTMENT continued Equipment Management Infection Control Compressed Gas Cylinders Medical Gas Safety Hospital Plan for Emergency Handling of Radiation Accident Cases Hazardous Materials and Waste RESPIRATORY THERAPY..108 SURGERY 108 What You Should Know to Limit Risks Needlestick Prevention Laser Safety TRANSPORTATION..110 Basic Safety Procedures Working on Vehicles Jump Starting UTILITIES & MAINTENANCE DIVISION 112 General Non-Routine Work Procedures Walking / Working Surfaces Welding / Cutting / Arc Welding Safety Machinery Painting and Spraying Boiler and Heater Rooms Electrical Safety Use of Fire Water for Non-Fire Fighting Purposes Compressed Gas Cylinders Ethylene Oxide Medical Gas Safety Heating, Ventilating and Air Conditioning (HVAC) Equipment and Environmental Tips from Utilities & Maintenance Project Management / Contractor Safety Hazardous Materials and Waste PROJECT MANAGEMENT/CONTRACTOR SAFETY.136 CHAPTER 6 SAFETY BY FUNCTION. 137 INFECTION PREVENTION.138 NEEDLESTICK PREVENTION BACK INJURY PREVENTION CATERING MEDICAL EQUIPMENT MANAGEMENT SAFETY

9 CHAPTER 6 SAFETY BY FUNCTION continued Basic General Guidelines Patient Care Equipment Safety Safety Evaluation of Medical Equipment Personal Equipment LADDER SAFETY..146 LASER SAFETY Laser Classification General Laser Safety Guidelines Standard Safe Operation RADIATION SAFETY Introduction Basic Safety Rules When Using Radioactive Materials Radioisotope Guidelines: Conditions of Use Hazards of Ionizing Radiation Exposure Application of Radiation Safety to Care of Patient Radiation Waste Disposal Radiation Accidents/Spills MACHINERY, CONSTRUCTION AND MAINTENANCE SAFETY.156 GENERAL OFFICE SAFETY Basic General Safety Guidelines Fire Safety CHAPTER 7 CONTROL OF EXPOSURE PLANS TO PRINCIPLE POLICY OF EMPLOYEE EXPOSURE TO RISKS 161 BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN.161 Preventive Methods of Exposure Contaminated Waste Handling and Disposal Training Chemical Hygiene Plan ANESTHETIC GAS EXPOSURE CONTROL PLAN 165 Anesthesia Apparatus Checklist Emergency and Waste Gas Disposal FORMALDEHYDE EXPOSURE CONTROL PLAN.166 Monitoring for Formaldehyde and Documentation Requirement Formaldehyde Waste is Sealed in Containers and Labelled GLUTARALDEHYDE EXPOSURE CONTROL PLAN 167 CYTOTOXIC / ANTINEOPLASTIC AGENTS EXPOSURE CONTROL PLAN..167 CHEMOTHERAPY DRUG SPILLS EXPOSURE CONTROL PLAN.169 ETHYLENE OXIDE EXPOSURE CONTROL PLAN General Procedures and Practices Central Supply Area Supervisor(s) Central Supply Area Employees Maintenance Ventilation Systems Alarm Systems - 9 -

10 CHAPTER 7 CONTROL OF EXPOSURE PLANS TO continued Installation of Gas Line Hand Valves Eyewashes and Showers Air Monitoring Personal Monitoring Emergency Plan and First Aid Procedures Hazard Communication CHAPTER 8 HAZARDOUS MATERIALS and WASTE 180 HAZARDOUS MATERIALS. 181 Hospital Plan Department Responsibilities Health Hazards Fire Hazards Reactive Hazards To Avoid Problems, Be Prepared Laboratory Chemicals Classes of Hazardous Materials Hazardous Material Emergency Training Decontamination Safe Storage and Handling of Hazardous Materials Chemical Group Precautionary Measures Degree of Hazard Identification for Hazardous Materials HAZARDOUS WASTE..192 Categorization of Hospital Waste Segregation Waste System Hazardous Waste Disposal Contract Conditions MATERIALS SAFETY DATA SHEETS (MSDS) CHAPTER 9 PERSONAL PROTECTIVE EQUIPMENT INTRODUCTION DISCUSSION ON TYPES OF PROTECTIVE EQUIPMENT..204 Head Protection Eye and Face Protection Hearing Protection Arm and Hand Protection Foot and Leg Protection Respiratory Protection Type of Hazard vs Selection of Respiratory Protection What PPE can do for you SELECTION OF PERSONAL PROTECTION BY JOB FUNCTION. 208 Food Services

11 CHAPTER 9 PERSONAL PROTECTIVE EQUIPMENT continued Housekeeping Laboratories Laundry Maintenance Materials Management Nursing Services Print Shop Radiology Surgery CHAPTER 10 ENGINEERING, CONTRACTOR AND PROJECT SAFETY KFSH&RC PROJECT ENGINEER BASIC GUIDELINES Factors to be Considered in Safety Evaluation of Prospective Contractor New Worker Orientation FUNDAMENTAL SAFETY RULES FOR CONTRACTORS AND CONSTRUCTION SITES..212 Abrasive Grinding Air Tools Concrete, Concrete Forms and Shoring Cranes and Derricks Disposal Chutes Electrical General Electrical Grounding Electrical Wiring and Portable Electrical Tools Entry into KFSH&RC Premises Equipment Excavating and Trenching Fire Protection Gas Cutting and Welding General Clothing and Hand Tools Housekeeping Ladders LPG Storage Facilities Painting Radiological Roof Work Scaffolding Work Permits Working Platforms JOB COMPLETION.230 INTERIM LIFE SAFETY MEASURES. 230 PRE-OCCUPANCY REQUIREMENTS CHECKLIST

12 CHAPTER 11 OFF-JOB SAFETY GENERAL GUIDELINES SWIMMING POOL SAFETY TRAFFIC SAFETY CHILDREN S PLAY GROUNDS FIRE SAFETY Prepare Yourself ELECTRICAL SAFETY KITCHEN SAFETY REMINDERS Microwave Oven Safety Food Handling Safety MEDICATION SAFETY COMMON FIRST AID TREATMENT FOR MINOR INJURIES.247 HOME HOUSEKEEPING TIPS SUMMARY..250 OTHER RELATED DOCUMENTS..251 RESOURCES CONSULTED 253 CHAPTER 12 APPENDIX Appendix A: Hospital ID Badges..258 Appendix B: Reporting Hazards Throughout the Hospital 260 Appendix C: Job Related Accidents and Illnesses with Lost Time. 261 Appendix D: Unauthorized Removal/Transfer of Fire & Safety Protection Equipment Appendix E: Conformity of Locks..263 Appendix F: Use of Small Appliances Within the Hospital Appendix G: Use of Transformers and Extension Cords Appendix H: Food in Hospital Premises.269 Appendix I: Use of Trolleys and Carts Throughout the Hospital Appendix J: Storage of Hazardous/Non-Hazardous Materials Appendix K: Request for Purchase of Safety and Fire Equipment and Materials Appendix L: Materials Handling Checklist..273 Appendix M: Characteristics of Medical Gas/Gas Maintenance Recommendations 275 Appendix N: Personally Owned Equipment Appendix O: Material Safety Data Sheets (MSDS) Appendix P: Compliance With Saudi Arabian Standards Appendix Q: Swimming Pool Safety Appendix R: Driving Safety

13 PREFACE This manual is a collection of detailed policies, procedures and guidelines that can be used to deal with or eliminate a variety of hazards that patients, visitors, employees and property of KFSH&RC are exposed to. The procedures, policies and guidelines are applicable to most of our Hospital s various functions, be they operations, medical service, administration, maintenance, engineering, contractor or other This manual should provide a practical, feasible and proven approach to implementing and maintaining effective safety and health programmes. This manual is designed for use by all KFSH&RC employees in general and line managers in particular, who are responsible for coordinating, directing, managing and inspecting safety or health in work areas that are under their responsibility. I ask Division Administrators, Chairman, Department Directors, Heads and Supervisors to review their work IPP s in order to update or establish to ensure safety is integrated into them. KFSH & RC Management believes that our place of work is safe because of you! Even though we have the approval of Management for this document to be used as a cornerstone for the safety guidelines that will help all staff, this is not a replacement for Department Internal Policies and Procedures (IPP s) or guidelines pertaining to safety